Efficacy of a Multiplex Paclitaxel Emission Stent Using a Pluronic® Mixture Membrane versus a Covered Metal Stent in Malignant Biliary Obstruction: A Prospective Randomized Comparative Study

BACKGROUND/AIMS: A drug-eluting stent for unresectable malignant biliary obstruction was developed to increase stent patency by preventing tumor ingrowth. The safety and efficacy of a new generation of metallic stents covered with a paclitaxel-incorporated membrane using a Pluronic® mixture (MSCPM-II) were compared prospectively with those of covered metal stents (CMSs) in patients with malignant biliary obstructions. METHODS: This study was initially designed as a prospective randomized trial but was closed early because of a high incidence of early occlusion. Therefore, the data were analyzed using the intent-to-treat method. A total of 72 patients with unresectable distal malignant biliary obstructions were prospectively enrolled. RESULTS: The two groups did not differ significantly in basic characteristics and mean follow-up period (MSCPM-II 194 days vs CMS 277 days, p=0.063). Stent occlusion occurred in 14 patients (35%) who received MSCPM-II and in seven patients (21.9%) who received CMSs. Stent patency and survival time did not significantly differ between the two groups (p=0.355 and p=0.570). The complications were mild and resolved by conservative management in both groups. CONCLUSIONS: There were no significant differences in stent patency or patient survival in MSCPM-II and CMS patients with malignant biliary obstructions.

Prognostic Factors and Scoring Model for Survival in Metastatic Biliary Tract Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Metastatic biliary tract cancer (mBTC) has a dismal prognosis. In this study, an independent dataset of patients with mBTC was used to implement and validate a routine clinico-laboratory parameter-based scoring model for risk group identification. MATERIALS AND METHODS: From September 2006 to February 2015, 482 patients with mBTC were assigned randomly (ratio, 7:3) into investigational (n=340) and validation datasets (n=142). The continuous variables were dichotomized using a normal range or the best cutoff values determined using the Contal and O'Quigley statistical methods. Following a Cox’s proportional hazard model, the scoring model was derived by summing the rounded chi-square scores for the factors identified by multivariate analysis. RESULTS: The performance status (Eastern Cooperative Oncology Group 3-4), hypoalbuminemia (< 3.4 mg/dL), carcinoembryonic antigen (≥ 9 ng/mL), neutrophil-to-lymphocyte ratio (≥ 3.0), and carbohydrate antigen 19-9 (≥ 120 U/mL) were identified as independent prognosticators (Harrell’s C index, 0.682; integrated area under the curve, 0.653). Survival was clearly correlated with the risk groups (low, intermediate, and high, 14.0, 7.3, and 2.3 months, respectively; p < 0.001). The prognosis was also discriminative in the validation data set (median survival, 16.7, 7.5, and 1.9 months, respectively; p < 0.001). Chemotherapy did not offer any survival benefits for high-risk patients. CONCLUSION: These proposed prognostic criteria for mBTC can facilitate accurate patient risk stratification and treatment-related decision-making.

Prognostic Scoring Index for Patients with Metastatic Pancreatic Adenocarcinoma / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: This study focused on implementation of a prognostic scoring index based on clinico-laboratory parameters measured routinely on admission in metastatic pancreatic cancer patients. MATERIALS AND METHODS: Records from 403 patients of metastatic disease were analyzed retrospectively. Continuous variables were dichotomized according to the normal range or the best cut-off values statistically determined by Contal and O’Quigley method, and then analyzed in association with prognosis—overall survival (OS), using Cox's proportional hazard model. Scores were calculated by summing the rounded chi-square scores for the factors that emerged in the multivariate analysis. RESULTS: Performance status, hemoglobin, leucocyte count, neutrophil-lymphocyte ratio, and carcinoembryonic antigen were independent factors for OS. When patients were divided into three risk groups according to these factors, median survival was 11.7, 6.2, and 1.3 months for the low, intermediate, and high-risk groups, respectively (p < 0.001). Palliative chemotherapy has a significant survival benefit for low and intermediate-risk patients (median OS; 12.5 months vs. 5.9 months, p < 0.001 and 8.0 months vs. 2.0 months, p < 0.001, respectively). CONCLUSION: We advocate the use of a multivariable approach with continuous variables for prognostic modeling. Our index is helpful in accurate patient risk stratification and may aid in treatment selection.

Gemcitabine Combined with Capecitabine Compared to Gemcitabine with or without Erlotinib as First-Line Chemotherapy in Patients with Advanced Pancreatic Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The purpose of this study is to retrospectively compare the efficacy and tolerability between three regimens for first-line chemotherapy-gemcitabine plus capecitabine (GEM-X), gemcitabine plus erlotinib (GEM-T), and gemcitabine monotherapy (GEM)-in patients with advanced pancreatic cancer. MATERIALS AND METHODS: There was a total of 127 patients who underwent chemotherapy for pancreatic cancer between January 2007 and November 2011 at our institution. Patients were treated with either GEM (gemcitabine 1,000 mg/m2 on days 1, 8, and 15 every 4 weeks), GEM-T (gemcitabine 1,000 mg/m2 on days 1 and 8 every 3 weeks and erlotinib 100 mg daily), or GEM-X (gemcitabine 1,000 mg/m2 on days 1 and 8 every 3 weeks and capecitabine 850 mg/m2 twice daily for 2 weeks followed by 1 week's rest) as the first-line treatment. Progression-free survival (PFS), overall survival (OS), objective response rate (ORR), and toxicity were evaluated. RESULTS: The patient population was divided into groups depending on their first-line treatment: GEM (n=47), GEM-T (n=44), and GEM-X (n=36). GEM-X significantly improved ORR (21.2% vs. 12.7% and 15.9%), PFS (8.9 vs. 5.2 and 3.9 months; p < 0.001), and OS (12.1 vs. 10.4 and 9.9 months; p = 0.03) compared to GEM and GEM-T, respectively. There were higher incidences of some non-hematologic adverse events with GEM-X and GEM-T compared to GEM, but most were grade 1 or 2. CONCLUSION: GEM-X presented better clinical efficacy and acceptable tolerability than GEM-T and GEM in advanced pancreatic cancers. It is worthy to further investigate which agent has a clinical advantage as a combination drug with gemcitabine in pancreatic cancer and to explore the predictive markers leading to personalize anti-cancer treatment.

Extrapancreatic Tumors in Intraductal Papillary Mucinous Neoplasm of the Pancreas / 대한소화기학회지

BACKGROUND/AIMS: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas has a favorable prognosis, but seems to be associated with a high incidence of extrapancreatic tumors. The purpose of this study was to evaluate the incidence and clinicopathological features of extrapancreatic tumors associated with IPMN. METHODS: Thirty-seven patients with IPMN of the pancreas, confirmed by surgical resection and typical findings of endoscopic ultrasonography and CT imaging between October 1, 1998 and August 31, 2006 were included. Seventeen patients were diagnosed with surgical resection and biopsy, and others by typical imaging findings of IPMN. These patients were examined for the development of extrapancreatic tumors. RESULTS: Of 37 patients with IPMN, 14 (38%) had 18 extrapancreatic tumors, and 10 (27%) had 13 extrapancreatic malignancies. Five, six, and two extrapancreatic malignancies had diagnosed before during, and after the diagnosis of IPMN. Gastric adenocarcinoma (3 patients, 23%) and colorectal carcinoma (3 patients, 23%) were the most common neoplasms. Other extrapancreatic tumors included lung cancer (n=2), prostatic cancer (n=1), renal cell carcinoma (n=1), cholangiocelluar carcinoma (n=1), urinary bladder cancer (n=1), and gallbladder cancer (n=1), respectively. As benign tumor, there were two gallbladder adenoma, one gastric adenoma, one colonic adenoma and one benign ovarian cystic neoplasm, respectively. CONCLUSIONS: IPMN is associated with high incidence of extrapancreatic tumors, particularly gastric and colorectal neoplasms. Upper gastrointestinal endoscopy and colonoscopy should be done, and systemic surveillance for the possible occurrence of other tumors may allow early detection of extrapancreatic tumor in patients with IPMN.

Two Cases of Percutaneous Transhepatic Choledochoscopy Treatment of Intrahepatic Duct Stones that Occurred after Living Donor Liver Transplantation / 대한소화기내시경학회지

Percutaneous transhepatic cholangioscopy (PTCS) is the primary treatment option for general cases of intrahepatic duct stones. However, there are no reports on the use of PTCS for intrahepatic duct stones in patients who had undergone living donor liver transplantation (LDLT). We experienced two cases of successful intrahepatic stone removal by the use of PTCS in LDLT patients. With these cases, we have confirmed that PTCS management can be safely performed not only for a general bile duct stone, but also for a bile duct stone that develops in a patient that had previously undergone liver transplantation.

Hematochezia with Colonic Polypoid Angiodysplasia in a Young Female Patient

A 18-year-old girl visited the hospital due to hematochezia. Colonoscopy revealed a 6-mm Yamada type II polyp with stigmata of bleeding, and a shallow ulcer on top was found at the cecum base. The polyp was removed by snare polypectomy, and hematochezia stopped thereafter. Angiodysplasia was diagnosed histopathologically. Generally, angiodysplasia appears as a flat or elevated, bright-red lesion on endoscopy, with a polypoid shape being extremely rare. This case is significant because the lesion occurred at the youngest reported age and was the smallest that has been reported, and is the only polypoid arteriovenous malformation to be discovered in the cecum.

Dilatation of Narrowed Pancreatic Duct Using a Soehendra Stent Retriever in Chronic Pancreatitis Patients / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic pancreatic ductal drainage may help alleviate the pain from chronic pancreatitis, but stricture dilatation may be technically difficult. Dilatation of high grade strictures of the pancreatic ducts with using dilating or balloon catheters may result in failure. We evaluated the efficacy of using the Soehendra stent retriever as a dilator. METHODS: Fourteen patients with pancreatic stricture had dilation performed with a Soehendra stent retriever. Each patient had sphincterotomy, guidewire placement and stent retriever dilatation. RESULTS: All procedures were successful and none of the patients had complications. Symptom relief was observed after dilation in all patients. There was no complication associated with the use of the stent retriever. None of the patients have relapsed for 6 months. CONCLUSIONS: The Soehendra stent retriever is safe and effective as a dilating device for the pancreatic strictures that are resistant to conventional dilation.

Endoscopic Sphincterotomy Plus Endoscopic Papillary Large Balloon Dilatation for Large Bile Duct Stones / 대한소화기내시경학회지

BACKGROUND/AIMS: The extraction of large common bile duct (CBD) stones after an endoscopic sphincterotomy (EST) is successful in 80~90% of cases but it often requires a prolonged time and repeated trials. This study investigated the utility of a combined endoscopic papillary large balloon dilatation (EPLBD) and a mid-incision of an EST (m-EST) method for the removal of large CBD stones. METHODS: Thirty patients with large CBD stones were enrolled in this study. EPLBD was carried out using the one-step inflation of a 15~18 mm diameter balloon after m-EST. RESULTS: The maximum stone diameter was 21.62+/-5.38 mm. Twelve patients had more than 4 stones, 7 patients had 2 stones, and the remainder had a single large stone. Complete ductal clearance was achieved in all patients. After the procedure, the serum amylase and/or lipase levels were elevated in 3 patients (13.3%). However, there was no episode of true pancreatitis. Minor bleeding was encountered in only one patient (3.3%), and was easily controlled by an endoscopic epinephrine injection. The procedure was carried out safely in 6 patients with periampullary diverticulum. No perforation or mortality was encountered. CONCLUSIONS: Combined EPLBD and m-EST is a safe and effective method, and may be a good alternative treatment for removing large CBD stones.

Mucin Expression Profile is Related to Biological and Clinical Characteristics of Intraductal Papillary-Mucinous Tumors of the Pancreas / 대한소화기학회지

No abstract availble.

Generation of Nitric Oxide in the Opossum Lower Esophageal Sphincter during Physiological Experimentation

Lipopolysaccharide (LPS), given in vivo, modulates opossum esophageal motor functions by inducing the inducible nitric oxide synthase (iNOS), which increases nitric oxide (NO) production. Superoxide, a NO scavenger, is generated during this endotoxemia. Superoxide is cleared by superoxide dismutase (SOD) and catalase (CAT) to protect the physiological function of NO. This study examined whether lower esophageal sphincter (LES) motility, NO release, and iNOS and nitrotyrosine accumulation in the LES are affected by LPS in vitro. Muscle strips from the opossum LES were placed in tissue baths containing oxygenated Krebs buffer. NO release was measured with a chemiluminescence NOx analyzer, and Western blots were performed to analyze iNOS and nitrotyrosine production. The percent change in resting LES tone after a 6-hour exposure to LPS was significantly increased compared to pretreatment values. The percent LES relaxation upon electrical stimulation was significantly decreased in the control group at 6 hours, indicating that the LPS treatment had an effect. The NO concentration in the tissue bath of LPS-treated muscle without nerve stimulation was significantly less than that of LPS treatment combined with SOD/CAT or SOD/CAT alone. iNOS and nitrotyrosine were detectable and increased over time in the LES muscle of both the control and LPS-treated groups. Antioxidant enzymes may play a role in regulating NO-mediated neuromuscular functions in the LES.

Tubular Adenoma of the Common Bile Duct: Endoscopic Diagnosis and Treatment / 대한소화기내시경학회지

Biliary adenoma of the common bile duct is a rare disease found in biliary tract encounterd in biliary mass lesion, and it is difficult to differentiate from their malignant counterparts. Symptoms and signs of these tumors can mimic choleliathiasis and malignant tumors. Therefore, this tumor is rarely diagnosed preoperatively. In addition, there has been no reported case of a tubular adenoma of the common bile duct in Korea, until recently. We experienced a case of tubular adenoma of the common bile duct, which was diagnosed and partially resected by percutaneous transhepatic cholangioscopy. The patient was a 84-year-old male who showed abnormal liver function test. Abdominal ultrasonography showed a dilated common bile duct, and a soft tissue was observed on endoscopic retrograde cholangiography. This was initially thought as a stone, but it became partially detachable from the common bile duct during an endoscopic retrograde cholangioscopic basket removal. The mass lesion was partially resected by a percutaneous transhepatic cholangioscopic snare. This resected tissue was confirmed as a tubular adenoma.

The Diagnostic Value of Endoprobe for Small Esophageal Leiomyomas Derived from the Muscularis Mucosae

Esophageal leiomyoma derived from the muscularis mucosae (MM) is a rare condition, and the optimal modality for diagnosis and treatment is controversial. Endoscopic ultrasonography can provide an accurate image of esophageal layer structure, providing information on lesion suitability for potential endoscopic therapy. We attempted to investigate the diagnostic value of a transendoscopic balloon-tipped miniature ultrasonic endoprobe for small esophageal leiomyomas derived from MM. We resected 7 small esophageal leiomyomas derived from MM by endoscopic mucosal resection (EMR), all of which were diagnosed by a balloon-tipped endoprobe. The endosonographic and pathologic features of 7 cases of small esophageal leiomyomas derived from MM were compared. The balloon-tipped endoprobe clearly showed all 7 small esophageal leiomyomas derived from MM, even those under 5 mm in size (smallest lesion, 3.0 mm). The endosonographic characteristics of small esophageal leiomyomas derived from MM were a hypoechoic mass with smooth, regular, and a well-defined outer margin and homogenous inner echogram arising from the second hypoechoic layer. Complete resections were possible in all 7 cases by EMR without any complications. Tumor size was 3.0 - 13.5 mm (mean 7.8 mm) in maximum diameter. In all cases, endosonographic findings by endoprobe were exactly concordant with pathologic finding in determining the tumors depth in the esophageal wall, tissue origin and characteristics, growth pattern, and size. We detail the balloon-tipped endoprobe is a simple, convenient, and very useful in making accurate diagnosis of small esophageal leiomyomas derived from the MM and the appropriate applications of EMR.

A Phase II Study of Capecitabine Combined with Gemcitabine in Patients with Advanced Gallbladder Carcinoma

Capecitabine and gemcitabine are used in the treatment of a variety of solid tumors including pancreatic and biliary tract carcinomas. The authors evaluated survival, response, and toxicity associated with using a combination of capecitabine and gemcitabine to treat patients with unresectable or metastatic gallbladder adenocarcinoma (GBC). Eligible patients had histologically- or cytologically-confirmed GBC, no prior systemic therapy with capecitabine or gemcitabine, Karnofsky Performance Status 70%, serum total bilirubin up to three times normal, and measurable disease. Treatment consisted of gemcitabine 1000 mg/m2 IV on Days 1 and 8 concurrent with administration of capecitabine 1000 mg/m2 PO BID on Days 1 through 14, on a 3-week cycle. Tumor response was assessed by the response evaluation criteria in solid tumors (RECIST criteria) and survival was calculated from initiation of CapGem therapy. A total of 24 patients were enrolled. Median age at the time of diagnosis was 62 years (range, 41-78 years). Fourteen patients had undergone prior surgery. Results showed that eight patients achieved partial response (33%) with an additional 10 patients achieving stable disease (42%). The overall median time to disease progression was 6.0 months (95% CI, 3.8-8.1 months) and overall survival was 16 months (95% CI, 13.8-18.3 months). The one-year survival rate was 58%. No Grade 4 toxicity was seen. Transient Grade 3 neutropenia/ thrombocytopenia and manageable nausea, hand-foot syndrome and anorexia were the most common toxicities. Our study shows that CapGem is an active and well-tolerated chemotherapy regimen in patients with advanced GBC.

An in-vitro evaluation of sealer placement methods in simulated root canal extensions / 대한치과보존학회지

The aim of this study was to evaluate the effectiveness of sealer placement in simulated root canal extensions. Forty resin blocks were attained from the Endo-training Bloc. In each block, the simulated root canal was made with #20, 08taper GT file. After each block was longitudinally split into two halves, a standardized groove was prepared on one canal wall of two halves to simulate the canal extensions with various irregularities. The two halves of each block were assembled and all simulated root canals were obturated by single cone method with AH26 sealer. Four different methods of sealer placement were used: group A, #20 K-file; group B, ultrasonic file; group C, lentulo spiral; group D, EZ-Fill bi-directional spiral. All obturated blocks were stored in 100% humidity at 37degrees C for 1 week. Using a low speed saw, each block was sectioned horizontally. Images of the sections were taken using a stereomicroscope at x 30 magnification and a digital camera. The amount of the sealer in the groove was evaluated using a scoring system, a higher score indicated better sealing effectiveness. The data was statistically analysed by Fisher's Exact Test. The sealing score was the lowest, specially at the middle area of canal extensions in group A, and that was statistically significant difference from other groups. In conclusion, the ultrasonic file, lentulo spiral and EZ-Fill bi-directional spiral were effective methods of sealer placement in simulated canal extensions. The K file was the least effective method, specially at the middle area of canal extensions.

Comparison of Rifaximin and Lactulose for the Treatment of Hepatic Encephalopathy: A Prospective Randomized Study

Rifaximin has been reported to be effective for the treatment of hepatic encephalopathy (HE) in Europe. However, it is unknown whether Rifaximin is effective for the treatment of HE in Koreans, therefore we conducted a open-label prospective randomized study to evaluate the efficacy of rifaximin versus lactulose in Korean patients. Fifty-four patients with liver cirrhosis and hepatic encephalopathy were enrolled. Thirty-two patients were randomized to receive rifaximin and 22 to receive lactulose both over a 7-day periods. Before and at the end of treatment, gradation of blood ammonia, flapping tremor, mental status, number connection test (NCT) were performed and estimation of HE indexes determined. Both rifaximin and lactulose were effective in the majority of patients (84.4% and 95.4%, respectively, p=0.315). Blood NH3, flapping tremor, mental status, and NCT was significantly improved by rifaximin and lactulose, and the post- treatment levels of these measures were similar for the rifaximin and lactulose-treated groups, as was the HE index (rifaximin group (10.0-->> 4.2, p=0.000) ; lactulose group (11.3-->> 5.0, p=0.000) ). One patient treated with rifaximin complained of abdominal pain, which was easily controlled. There was no episode of renal function impairment in either treatment group. Rifaximin proved to be as safe and as effective as lactulose for the treatment of Korean patients with hepatic encephalopathy.

Endoscopic Ultrasonographic Findings of Two Cases of Parasitic Eosinophilic Granuloma in the Stomach / 대한소화기내시경학회지

Anisakiasis is a disease of the alimentary tract caused by nematode larva belonging to the subfamily Anisakinae. It is possible for Anisakis larva to be transmitted to man through eating raw sea fish that is preferred by Korean people. The clinical symptoms are characterized by severe cramping abdominal pain, nausea, vomiting, diarrhea, tarry stool, and epigastric fullness. The endoscopic examination has played a important role in the diagnosis of anisakiasis. However, gastric anisakiasis is undetected due to unspecific symptom and delayed endoscopy. Endoscopic ultrasonography is probably the choice of investigative tool for the evaluation of submucosal mass. However distinctive feature of parasitic infectation presenting an submucosal tumor has not been reported. Recently, we experienced two cases of gastric anisakiasis. We found gastric submucosal tumors by endoscopy, differentiated them by endoscopic ultrasonography and treated by endoscopic submucosal resection.

Effect of canal tapering in teeth of various apical size & cross-sectional configuration on microleakage / 대한치과보존학회지

The aim of this study was to evaluate the microleakage of teeth according to root canal preparation with & without apical enlargement in various size of apical foramen. 60 extracted one canal roots were cross-cutted at 5 mm from root apex and divided into two groups according to their apical foramen size of large (L) and small (S). Each group was subdivided into two groups accordance with their cross-sectional configuration at 5 mm from apex, round (R) and ovoid (O); SR Group, SO Group, LR Group, LO Group. Each group was shaped in .02 taper by Quantec series Nickel-Titanium (NiTi) rotary file, obturated by lateral condensation method. Leakage was measured using a fluid transport model under 40 cmH2O pressure. After the leakage test, blocks which had showed the leakage retreated with .04 taper and .06 taper and evaluated the degree of fluid filtration in each group. The data was analysed statistically using chi-square test and fisher's exact test. The results obtained were as follows: 1. Significant difference in leakage was found in groups which had different apical foramen size in .02 taper instrumentation (p 0.05). 2. The difference in microleakage according to the shape of canal was not evident at 5 mm from apex (p > 0.05). 3. There was correlation between .02 taper instrumentation and .04 taper instrumentation in LR group , LO group (p < 0.05).

A Case of Acromegaly with Gall Bladder Cancer / 대한내분비학회지

Acromegaly is a systemic endocrine disorder due to an excessive release of growth hormone, which increases the serum levels of insulin-like growth factor-1(IGF-1). Elevated levels of these hormones are assumed to increase the incidence of malignant tumors in patients with acromegaly, due to by stimulating the growth and maturation of cells. In particular, IGF-1 is considered to be closely related with the development of colon polyps and colon cancers. Studies suggest that various malignant tumors, including thyroid cancer, brain tumor and renal cell carcinomas, are also more common in patients with acromegaly. Here, a case of gall bladder cancer in a patient with acromegaly, and the possible relationships between these two disorders, is reported.

Ovarian Cystadenofibroma in a Patient with Familial Adenomatous Polyposis / 대한소화기내시경학회지

Familial adenomatous polyposis (FAP) is a hereditary disease characterized by the appearance of numerous polyps in the large bowel with a high potential for malignant transformation unless untreated. A variety of extracolonic manifestations were reported such as osteoma, epidermoid cyst, desmoid tumor, gastroduodenal polyps, small bowel tumor, congenital hypertrophy of the retinal pigment epithelium, hepatobiliary tumor, thyroid tumor, and tumor of the central nervous system. However, the ovarian involvement of FAP as an extracolonic manifestation was very rare and there have been only few reports. We experienced a rare case of ovarian cystadenofibroma in a patient with FAP as an extracolonic manifestation. We also found colon cancer with multiple hepatic metastasis initially manifested as intestinal obstruction in the same patient. Surgical treatment and subsequent chemotherapy for colon cancer and intraoperative radiofrequency ablation of hepatic metastasis were performed.